Surgical options for early arthritis in young persons and athletes: the role of meniscus transplants, microfracture, Osteoarticular Transplants (OATs), Autologous Chondrocyte Implantation (ACI) and osteotomy

Edited By: Christopher J. Wahl, M.D., Suzanne L. Slaney, PA-C, ATC, MMS
Last updated Friday, June 30, 2006

Figure 1. Arthroscopic and x-ray view of the knee. The joint line of the knee that shows up on x-rays is not an empty space (red circle). The “space” is occupied by articular (AC) and meniscal (M) cartilage. Articular cartilage provides a frictionless gliding surface for motion and helps transmit weight across the joint. The knee has 2 meniscal cartilages (medial = inside and lateral = outside). These make the joint more congruent, absorb shock, and transmit forces across the joint.

Figure 2. Knee x-ray with arthroscopic views. A. The lateral femoral condyle (LFC) is covered with smooth, white articular cartilage. B. The lateral meniscus (LM) is sandwiched between the LFC and tibial plateau. C. The lateral tibial plateau (LTP) is covered with articular cartilage, and normally hidden underneath the LM. D. The medial femoral condyle (MFC) is also covered by articular cartilage. E. The medial meniscus (MM) covers a smaller portion of the medial tibial plateau (MTP).

Figure 3. X-ray of a right knee at the patellofemoral joint with arthroscopic views (inset). The patellofemoral joint is the joint between the “undersurface” of the patella (kneecap) and the front aspect of the femur. A. The undersurface of the patella (P) is covered with smooth, white, gliding articular cartilage. B. The anterior aspect of the femur has a groove called the trochlea (T) in which the patella rides. There is no meniscus in the patellofemoral joint.

Figure 4. Arthroscopic views of the medial (inside) joint of the knee. A. The femur (F) exhibits the irregularity and wear of moderate arthritis. There is also fraying of the edge of the meniscus (M). The tibial side of the joint (T) has only mild arthritic changes. B. The tibia (T) in the image to the right has severe arthritis, with exposed bone beneath frayed, fragmented articular cartilage. The meniscus (M) is normal in appearance, as is the femur’s articular cartilage (F).

Summary

What are the key points about microfracture, meniscal transplantation, osteoarticular allograft/autograft transplants (oats), autologous chondrocyte implantation (aci) and ostotomy for arthritis in the athlete. for arthritis, osteochondral defects (ocd lesions), meniscus transplantation and cartilage loss in the knee.?

Articular cartilage is a smooth, gliding surface material which covers the ends of your bones at the joints. Think of it like the non-stick TeflonÒ coating in a pan.  Articular cartilage decreases the friction that occurs when your joints move.  When the cartilage becomes injured or worn, the joint gliding can be impaired and become painful.  Injuries or wear to the articular cartilage can manifest as joint pain, clicking, locking, or swelling which can impair function.

Unlike many tissues in the body, the articular cartilage does not have the capacity to heal well.  This is in part because it has a relatively poor blood supply (and thus is not served by the body’s usual reparative inflammatory response) and in part because cartilage wear is most commonly a result of many factors, including the joint alignment, a patient’s activity level, and genetic factors.

What are the different treatment options for injuries to the cartilage?

There are a number of different therapies, techniques, and procedures which can be used to treat injuries or prevent further wear to the articular cartilage.  The treatment that is best for you depends on the type of injury you have, the types of activities you perform, your age, and other associated injuries and medical history.  The medical modalities include:

• Non-Steroidal Anti-Inflammatory Drugs (NSAID’s)
• Physical therapy
• Injections with anti-inflammatory medications or viscosity agents

There are a series of surgical options for more severe cartilage injuries:

• Arthroscopic lavage and debridement
• Microfracture
• Meniscus transplantation (for loss of the meniscal cartilages)
• Osteochondral grafting or Osteoarticular Autograft Transplants (OAT’s)
• Autologous Chondrocyte Implantation (ACI)
• Osteotomy/Realignment to re-establish a normal joint axis
• Joint Arthroplasty/Replacement

Each of the above surgical modalities has a potential role in the treatment of focal arthritis, and studies have shown that there are optimal indications for each.  In some cases, the procedures should be combined (e.g. an osteotomy to re-align the limb and an OATs procedure to restore a normal cartilage surface).

For many persons, a conservative approach with physical therapy (strengthening and stretching), Non-Steroidal Anti-Inflammatory Medications (NSAIDs), loss of excess weight, and occasionally orthotics may lessen the symptoms of cartilage lesions to a great degree.  When these modalities have been tried in earnest and fail to provide relief, surgical cartilage restorative procedures can be considered.   

The nature of the injury to the cartilage will usually dictate which option is best to treat the problem.  In most cases, X-rays, Magnetic Resonance Imaging Studies (MRI) and occasionally arthroscopy may be required to evaluate the injury to determine the best treatment.  Based on the findings, the experienced surgeon can choose from an armamentarium of procedures to address the injured cartilage tissue and correct any limb alignment problems that may be contributing to the injury.

While some of the procedures (debridement, microfracture, OATs) can be performed arthroscopically (using very small incisions), occasionally minimally-invasive open procedures are performed through small incisions.  Depending on the procedure performed, the rehabilitation period can be extensive, particularly in weight-bearing joints like the knee or ankle.  

Arthroscopy helps a physician evaluate and treat knee arthritis. Using the scope, an experienced surgeon can evaluate the entire knee joint and can identify the injured structures of the knee, including injuries to the ligaments, articular cartilage surfaces, and meniscal cartilages.  Figures 2 and 3 show the normal appearance of the medial (inside), lateral (outside), and patellofemoral (kneecap) joint surfaces of the knee.  Figure 4 and Video 1 shows regions of a knee with severe cartilage damage.  Results are most predictable in the hands of a highly-specialized surgical team that is familiar with various techniques and instrumentation, and who perform such surgery often.  Such a team will maximize the benefits and minimize the risks.  The procedure usually takes a few hours to perform, and the patient may require a hospital stay of 1 to 2 days.

• Video 1. Arthroscopy of a knee with focal arthritis.  A region of normal, intact cartilage surrounds a region of fragmented, damaged cartilage.  There is a small region of bone exposed beneath the cartilage. (wmv 3.56MB)
  

Surgery for Arthritis, osteochondral defects (OCD lesions), meniscus transplantation and cartilage loss in the knee. at the University of Washington

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